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Key Terms

  • ADL – Activities of Daily Living. Clinicians assess a patient's ability to perform these daily activities independently. Based on physical, emotional and mental functioning, clinicians provide treatments and interventions to support the patient with daily activities such as dressing, eating, ambulating, toileting and personal hygiene.
  • ASP – Application Service Provider. Business that provides application software to users through a web browser. The software typically resides on the vendor's system thus eliminating the need for customers to host the application on their own computer servers. Software offered using an ASP model is also called "On-Demand Software" or "Software As A Service".
  • CCR – Continuity of Care Record. A patient health summary standard designed to permit creation of flexible documents that contain the most relevant and timely core health information about a patient and the electronic transmission of these documents from one caregiver to another.
  • CNA – Certified Nursing Assistant or Aide. CNAs assist residents or patients with activities of daily living (ADLs) and provide care and basic nursing procedures under the supervision of a Registered Nurse or Licensed Practical Nurse.
  • CPOE – Computerized Provider Order Entry. Clinical application that allows health care providers to order and process lab tests, medications, clinical procedures, and other services electronically. Routing important requests for patient care occurs almost instantaneously.
  • DUR – Drug Utilization Review. The practice of drug utilization review ensures patient safety and manages medication therapy by examining a patient's physician orders and checking for drug-drug, drug-allergy, drug-food, and drug-condition interactions using patient factors such as gender, age, weight, medical history and current treatments.
  • EDI – Electronic Data Interchange. Computer-to-computer exchange of structured information, by agreed message standards, from one computer application to another by electronic means and with minimum human intervention.
  • EHR – Electronic Health Record. Extends the EMR concept to include cross-institutional data sharing. An EHR may also reside within a single institution, linking affiliated practice sites together. All participating sites must have an interoperable EMR in place.
  • EMR – Electronic Medical Record. Set of databases that contain health information for patients within a given institution or organization, compiled from a variety of sources.
  • ERX – Electronic Prescription or Electronic Prescribing. Use of electronic devices to enter, modify, review and output or communicate drug prescriptions. Electronic prescribing will be required by 2009 as established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
  • FDA – Food and Drug Administration. The FDA is an agency of the US Department of Health and Human Services and is responsible for regulating food, dietary supplements, drugs, biological medical products, blood products, medical devices, radiation-emitting devices, veterinary products, and cosmetics.
  • HIPAA – Health Insurance Portability and Accountability Act. Enacted by the US Congress in 1996: Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. The AS provisions also address the security and privacy of health data. The standards are meant to improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in the US health care system.
  • HIE – Health Information Exchange. Mobilization of healthcare information electronically across organizations within a region, community or hospital system. The goal of the HIE is to facilitate access to and retrieval of clinical data to provide safer, more timely, efficient, effective, equitable, patient-centered care.
  • HIT – Health Information Technology. As the US Government Accountability Office (GAO) and others have reported, the use of information technology (IT) has enormous potential to improve the quality of health care and is critical to improving U.S. health care system performance.
  • MAR – Medication Administration Record. Record of the drugs administered to a patient at a facility by a nurse or other healthcare professional. The nurse or healthcare professional signs off on the record at the time that the drug is administered. eMAR is an electronic medication administration record.
  • MDS – Minimum Data Set. The MDS is part of the US federally mandated Resident Assessment Instrument (RAI) process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's mental and functional capabilities and helps nursing home staff identify health problems. MDS assessments are required for all residents on admission to the nursing facility and then on days 5, 14, 30, 60, & 90 day, and periodically as needed for significant changes in the resident's condition. The 5-day assessment covers payment for days 1 - 14; 14-day for days 15 - 30; etc. The Centers for Medicare & Medicaid Services (CMS) requires that the MDS be submitted electronically to the State database. When the assessment is required for payment, a Resource Utilization Group (RUG) is assigned to the assessment.
  • OBRA – Omnibus Budget Reconciliation Act. OBRA of 1987 mandated that an assessment be designed and used across the nation to determine each long-term care residentís functional capabilities. This assessment was to lead to the development of an individualized care plan. The Resident Assessment Instrument (RAI) and the Minimum Data Set (MDS) were created in response to this requirement.
  • OTC – Over the Counter. Medications that may be sold without a prescription and without a visit to a medical professional, in contrast to prescription drugs.
  • PDA – Personal Digital Assistant. A handheld electronic device which includes some of the functionality of a computer such as an Internet browser, email, scheduling, and personal contacts.
  • PPS – Prospective Payment System. The US Balanced Budget Act (BBA) of 1997 modified how payment is made for Medicare skilled nursing facility (SNF) services. Effective in 1998, SNFs are paid on the basis of a per diem prospective payment system (PPS) covering all costs (routine, ancillary and capital) related to the services furnished to beneficiaries under Part A of the Medicare program. Per diem payments for each admission are case-mix adjusted using a resident classification system (Resource Utilization Groups or RUGs) based on data from resident assessments (MDS) and relative weights developed from staff time data.
  • RAI – Resident Assessment Instrument. The instrument is comprised of the MDS and utilization guidelines and provides a comprehensive, accurate, standardized, reproducible assessment of each long-term care facility residentís functional capabilities and identifies medical problems. The RAI helps facility staff to gather definitive information on a residentís strengths and needs, which must be addressed in an individualized care plan. It also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the residentís status.
  • RHIO – Regional Health Information Organization. Multi-stakeholder organization responsible for motivating and implementing the exchange of information among stakeholders in a particular region in order to positively impact the safety, quality, and efficiency of healthcare as well as access to healthcare through the efficient application of health information technology.
  • RUG – Resource Utilization Group. Skilled nursing facilities (SNF) receive per diem payments for each admission, which are case-mix adjusted using a resident classification system, Resource Utilization Groups (RUG) III, based on data from resident assessments and relative weights developed from staff time data. Using the data from MDS assessments, residents are classified into RUG-III groups based on need for therapy (i.e., physical, occupational, or speech therapy), special treatments (e.g., tube feeding), and functional status (e.g., ability to feed self and use the toilet.) When the assessment is required for SNF payment, a Resource Utilization Group (RUG) is assigned and submitted to the State.
  • TAR – Treatment Administration Record. Record of the treatments administered to a patient at a facility by a nurse or other healthcare professional. The nurse or healthcare professional signs off on the record at the time that the treatment or device is administered. eTAR is an electronic medication treatment record.
  • WIFI – Wireless Fidelity. The term WiFi is used to described the wireless networking of mobile computing devices, such as computers and printers.